Cesarean section rates in New Jersey have declined over the past several years due in large measure to a greater focus on quality assurance programs designed specifically to lower the number of C-section births.
According to the Centers for Disease Control & Prevention, New Jersey has the fourth-highest rate of C-sections in the nation at 35.9 percent compared to the national rate of 32 percent.
Kerry McKean Kelly, vice president for communications and member services at New Jersey Hospital Association said that hospitals have been focused on this issue for several years and although the numbers are coming down, a lot more needs to be done.
“A C-section to deliver your first baby all too often becomes a C-section for all subsequent deliveries — that’s why it’s important for us to focus on reducing the number of C-sections in first-time births, wherever appropriate,” she said. “From safe delivery to healthy babies, that’s the number one goal in New Jersey.”
By the numbers
The Leapfrog Group, which measures quality and safety of American health care, sets a standard for C-sections at 23.9 percent.
Leapfrog tracks Nulliparous Term Singleton Vertex C-sections, which occur when a first-time mother with a normal, uncomplicated, low-risk pregnancy ends up having a C-section.
Data from the 2018 Leapfrog Hospital Survey covering one of two 12-month time periods — Jan. 1, 2017 to Dec. 31, 2017 or July 1, 2017 to June 30, 2018 — show that New Jersey hospital C-section rates ranged from 12.8 percent to 55 percent.
“We’re really happy to see that hospitals are acknowledging that it is a problem and they can do something about it and that we are a partner for them,” said Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute.
The New Jersey Perinatal Quality Collaborative housed at the NJHA’s Institute for Quality and Patient Safety works with the New Jersey Department of Health to reduce NTSV C-sections.
Guidelines from The Alliance for Innovation on Maternal Health, a national group established to promote consistent and safe maternity care to reduce maternal mortality, are being used in New Jersey as part of The New Jersey Perinatal Quality Collaborative.
The focus on reducing C-section rates has resulted in a major cultural shift that has precipitated policy changes within the OB-GYN community.
“Over the last two years we have begun an initiative to reduce unnecessary C-sections which has brought us to numbers in the mid-20s, well below the average for the state,” said Dr. Manuel Alvarez, chairman OB-GYN Hackensack University Medical Center.
“Our aim was to finish 2017 and 2018 with a rate below 29 percent and now we are working on initiatives to bring that even lower to perhaps 23 percent,” said Alvarez.
C-section rates at Hackensack Meridian hospitals range from 26.3 percent to 34.0 percent, according to the Leapfrog survey.
Issuing report cards
Alvarez said that the hospital has taken a multi-faceted approach to reducing C-sections including implementing a set of systems that includes educating all health care professionals and initiatives like tracking C-sections on a daily basis and issuing report cards on physicians’ statistics.
Alvarez said the OB-GYN department at Hackensack University Medical Center formed a multidisciplinary group “which encompasses obstetricians from the faculty service and the voluntary service, nursing and anesthesia to meet on a weekly basis to modify policies in regard to C-sections.” He added that the hospital administration and the network supports the C-section initiative.
Morristown Medical Center is pursuing a similar strategy and is taking an aggressive, system-wide approach to reducing C-section rates.
“We have active dashboards that we are watching almost daily and we have engaged the physicians to participate,” said Dr. Diana Contreras, who chairs OB-GYN and Women’s Health at the hospital.
“We have been able to give people their data and have tried to educate the physicians, the midwives and the patients about how important it is that we consider what goes on with mom as much as what happens for the baby,” said Contreras.
Morristown Medical Center’s C-section rate is 27.1 percent.
Suzanne Spernal, vice president Women’s Services at RWJBarnabas Health said that the system has an obstetrics collaborative that connects all eight of its birthing hospitals.
“We use research and quality improvement initiatives and we all participate in statewide outreach to improve health outcomes for moms and babies because we recognize how critically important it is to support women during and after their birthing experience.”
RWJBarnabas hospital’s C-section rates range from 24.6 percent to 27.9 percent.
A spokesperson for Englewood Health told NJBIZ that its rate of C-sections decreased 12 percent from 2017 to 2018 and the rate of early elective delivery decreased by 85 percent.
As one of the busiest maternity programs in the northern part of the state, Englewood averages more than 2,500 births a year. Englewood’s C-section rate is 26.3 percent, according to Leapfrog.
Cooper University Hospital has one of the lowest C-section rates in the state at 12.8 percent.
Dr. Robin Perry, chairman and chief of the Department of Obstetrics and Gynecology, said that as a regional perinatal center, Cooper serves a high-risk population and has been diligent in reducing C-section rates and supporting vaginal birth whenever possible.
“As an academic tertiary hospital, all of Cooper’s OB-GYNs serve as attending physicians as well as faculty members at Cooper Medical School of Rowan University,” Perry said. In these dual roles, they work to safeguard that every C-section performed at Cooper has a clear evidence-based indication.”
A Level 1 Trauma Center, Perry said that Cooper has 24/7 obstetric anesthesia support and can safely offer a trial of labor after a cesarean section — which for many women results in a vaginal birth after cesarean (VBAC), helping to reduce repeat C-sections.
While the decrease in C-sections has been lauded in the medical community, some physicians contend that more can be done to reduce rates ever further.
‘The root of the problem’
“A large amount of medical research, hospital initiatives, and national debate is currently centered on reducing the cesarean rate. Unfortunately, most of those things are focused on how the implementation of the medical model can be modified in order to achieve that goal, rather than examining how the model itself and the philosophy behind it may be the root of the problem,” said Dr. Michelle Aristizabal, an OB-GYN in Montclair. “When maternity care is delivered within different, less aggressive models, such as the natural or midwifery models of care, cesarean rates are significantly lower,” she explained.
Aristizabal, who recently wrote a book titled “Natural Labor and Birth; An Evidence-Based Guide to the Natural Birth Plan,” said that The American College of Obstetrics and Gynecology has come a long way in supporting patients who seek lower intervention models of care.
In the last three years, Aristizabal said there have been several committee statements with specific recommendations to reduce the rate of cesarean, promote lower intervention care models, and support VBACs.
“While natural birth community is trying to encourage the use of midwives, most women still deliver with physicians, so unless physicians work to develop other practices, the rate is not going to significantly change,” said Aristizabal. “Hospitals are offering better facilities, with mobile monitors and hydrotherapy, and working with their physicians to adopt better practices that reduce the rate of cesareans.”